대한류마티스학회지 Vol. 18, No. 3, September, 2011 http://dx.doi.org/10.4078/jrd.2011.18.3.153 REVIEW 섬유근통증후군의새로운진단기준과임상적의의 이신석 전남대학교의과대학류마티스내과학교실 Newer Diagnostic Criteria of Fibromyalgia and Its Clinical Implications Shin-Seok Lee Department of Rheumatology, Chonnam National University Medical School, Gwangju, Korea Since Smythe and Moldofsky proposed the first modern definition of fibromyalgia (FM), a number of different classification and diagnostic criteria have emerged. Among these criteria, the 1990 American College of Rheumatology (ACR) classification criteria have been the most widely accepted in both research and clinical settings. The 1990 ACR criteria were originally established as inclusion criteria for research purposes and were not intended for clinical diagnosis, but have become the de facto diagnostic criteria in clinical settings. However, an improved clinical case definition for FM, using diagnostic criteria that can be used by both primary care physicians and specialists has been desired for a long time. For this, Wolfe and colleagues developed several sets of diagnostic criteria and their last one received the endorsement of ACR, which is now known as the 2010 ACR diagnostic criteria. Unfortunately, the new criteria have been criticized as being inconsistent, non-specific, and lacking the ability to recognize FM concurrent with other diseases. Further studies are needed to assess the acceptance, reliability, and validity of the new criteria in epidemiologic and clinical studies. Key Words. Fibromyalgia, Diagnostic, Criteria 서론섬유근통증후군 ( 이하섬유근통 ) 은전신적인통증과특정부위의압통점을특징으로하는만성근골격계질환이다. 1990년미국류마티스학회의분류기준이만들어지면서섬유근통에관한연구가본격화되었고 (1) 유전적인소인이있는사람들이특정환경인자에노출되었을때발병한다는사실과중추신경계에서통증을조절하는데문제가있어섬유근통이발생한다는사실등이근래에새롭게밝혀지게되었다 (2). 섬유근통은비교적최근에연구가활성화되어단기간에새로운발견들이추가되고있는대표적 < 접수일 :2011 년 9 월 1 일, 심사통과일 :2011 년 9 월 12 일 > 통신저자 : 이신석광주시동구학동 5 번지전남대학교의과대학류마티스내과학교실 E-mail:shinseok@chonnam.ac.kr 인질환으로 2010년 5월미국류마티스학회의섬유근통진단기준이 20년만에새롭게개정됨에따라환자진료와연구에새로운국면을맞이하고있다. 국내에서치료에사용되고있는약제들의보험급여가이루어지기위해서는 1990년분류기준을만족해야하는데앞으로는 2010년진단기준으로보험급여가이루어질예정이어서새로운진단기준에대한관심이그어느때보다높다고할수있다. 먼저섬유근통의진단기준들을고찰하기전에진단의중요성을살펴보면진단자체만으로도환자의건강만족도를향상시킬수있다는점이다. 섬유근통환자들은다양한임상증상으로인해삶의질이떨어져있고진단에이르는데많은시간이소요되기때문에진단자체만으로도건강상태에긍정적인효과를가져올수있다 (3). 또한적절한진단을통해불필요한혈액검사와방사선촬영을줄일수있고불필요한약물복용도줄일수있으며협진의빈도도줄일수있기때문에적절한진단기준을사용하여조기에진단을하는것이중요하다고할수있다 (4). 본종설에서 153
154 이신석 는새로운진단기준이발표되기까지기존의진단기준들을살펴보고이들을서로비교하여새로운진단기준이갖는임상적의의들을알아보고자한다. 본론섬유근통이의학적으로처음알려지게된것은 1904년 Gowers가전신적인통증을 섬유조직염 (fibrositis) 으로기술하면서부터이다 (5). Gowers는피하조직과섬유조직에염증이생겨전신적인통증이발생하는것으로가정하였는데이것은후에조직학적으로증명된적이없어적절치못한용어로받아들여져왔다. 섬유근통이라는용어는 1976년 Hench에의해서처음으로사용되었는데 Hench는만성통증이있으면서다양한검사에이상소견이없을때섬유근통으로진단할수있다고하였다 (6). 이것은일종의용인 (rule in) 기준이라기보다는배제 (rule out) 기준으로서환자가호소하는증상에대해영상의학적검사를포함한가능한모든검사를실시하여기질적인이상이없다는것을증명해야하므로엄밀한의미의진단기준으로보기는어렵다. 용인기준으로서가장최초의진단기준은 Smythe와 Moldofsky의 1977년진단기준이다 (7). 표 1에서보는것처럼만성통증, 수면장애, 조조강직, 피로와같은임상증상이있으면서 14군데의압통점가운데 12군데이상에서압통을호소할때섬유근통으로진단할수있다고하였다. 이기준이갖는의미로는첫째, 최초로압통점을섬유근통의진단기준에포함시켰다는것이다. 여기에언급된 14군데의압통점은 1990년미국류마티스학회의분류기준에나오는 18군데의압통점과거의일치하기때문에 1990년분류기준은 Smythe와 Moldofsky의 1977년진단기준에서유래된것임을알수있다. 둘째로는수면장애를섬유근통의주요증상으로인식해서이를진단기준에포함시켰다는것이다. 특히, Moldofsky는섬유근통환자의뇌파검사 Table 1. Smythe and Moldofsky criteria (1977) 1. Chronic aching, non-restorative sleep, a marked morning stiffness, fatigue 2. Tender points in at least 12 out of 14 sites Adapted from reference (7). Table 2. Smythe criteria (1979) 1. Widespread aching of more than 3 months duration 2. Local tenderness at 12 of 14 specified sites 3. Skin roll tenderness over the upper scapular region 4. Disturbed sleep, with morning fatigue and stiffness 5. Normal ESR, SGOT, RF, ANA, muscle enzyme and sacroiliac films Adapted from reference (9). 를통해깨어있는상태나빠른눈운동수면 (REM sleep) 시에나타나는알파파가느린눈운동수면 (non-rem sleep) 시에나타나는 알파파의침입 (intrusion) 을최초로보고하였고이러한현상이섬유근통의통증이관련이있음을밝힌바있다 (8). Smythe는이후에 1977년진단기준을수정하여 1979년에새로운진단기준을발표하였다 (9). 표 2에서보는것처럼 1979년기준에서는 3개월이상지속되는통증을만성통증으로정의하였고승모근위쪽의피부를손가락으로말면서굴렸을때통증을호소하는 roll tenderness 를새로운진단기준에포함시켰다. 또한류마티스인자, 항핵항체, 적혈구침강속도, 아스파르테이트아미노전달효소 (AST, SGOT), 근육효소수치와같은검사실소견과천장관절 X-ray에이상이없어야한다는것도진단기준에포함시켰다. Smythe의 1977년과 1979년두진단기준의가장큰문제점은실제섬유근통환자들을대상으로정상혹은환자대조군과비교하여섬유근통환자들이대조군과구별되는특징들을도출하여만든진단기준이아니라는것이다. 즉, 개발자의경험에의지하여만들어진진단기준으로근래에만들어진진단기준들과는상당히거리가있는진단기준으로볼수있다. 실제섬유근통환자들을대상으로한최초의진단기준은 1981년 Yunus 등이발표한진단기준이다 (10). Yunus는 50 명의섬유근통환자와나이와성별이일치한 50명의정상대조군을비교하였는데통증, 피로, 수면장애, 압통점의빈도가환자군에서유의하게높아이들이섬유근통의특징적인증상이라고하였다. 또한주관적인부종, 감각이상, 과민대장증후군, 긴장형두통, 편두통도환자군에서높은빈도를보여이역시대조군과구별되는특징적인증상이라고하였다. 이진단기준은처음으로민감도와특이도 Table 3. Yunus criteria (1989) 1. Major criteria Presence of 2 or more of 6 historical variables (hurt all over, pain at 7 or more sites, general fatigue, poor sleep, anxiety/ tension, irritable bowel syndrome), plus 4 or more of 14 specified tender points* 2. Minor criteria Presence of 3 or more of 6 historical variables, plus 2 or more tender points 3. Obligatory criteria A. Presence of pain or stiffness or both, at 4 or more anatomic sites (counting unilateral or bilateral involvement as one site) for 3 months or longer B. Exclusion of an underlying condition which may be responsible for the overall features of fibromyalgia *Upper mid-trapezius, lower sternomastoid muscle, lateral pectoral muscle, mid supraspinatus muscle, upper lateral gluteal region, greater trochanteric region, medial fatty pad of the knee. Sensitivity of 92% and specificity of 94% for rheumatic conditions. Adapted from reference (11).
섬유근통의새로운진단기준 155 를제시하였는데정상대조군에대해각각 96% 의민감도와 100% 의특이도를나타냈다. 이기준은이후몇차례의수정을거쳐표 3의형태로굳어졌는데 1990년미국류마티스학회의분류기준이발표되기전까지가장널리사용된진단기준이였다 (11). 표 3의내용을살펴보면섬유근통으로진단되기위해서는 14군데의압통점가운데 4군데이상에서압통이있어야하고 6개의특징적인증상 ( 전신통증, 7부위이상의통증, 피로, 수면장애, 불안, 과민대장증후군 ) 가운데적어도 2개가있어야한다고했다. 또한 14군데의압통점가운데 2군데이상에서압통이있으면서 3개이상의특징적인증상이있는경우에도섬유근통으로진단할수있다고하였다. 이진단기준은마치미국류마티스학회의 1990년분류기준과 2010년진단기준을합쳐놓은것같아앞으로이세기준의민감도와특이도를비교해보는것도상당히흥미로울것같다. 1990년미국류마티스학회의분류기준을살펴보기전에언급될필요가있는진단기준으로 1989년에발표된 Lautenschläger 등의진단기준이있다 (12). 표 4에보는것처럼두가지내용으로구성되어있는데허리를기준으로신체 Table 4. Lautenschläger criteria (1989) 1. Spontaneous pain in at least three body regions 2. Multiple tender points >11 out of 24 sites In doubtful cases, additional vegetative and functional symptoms should be considered. Sensitivity of 95% and specificity of 96% for the cut-off in the tender point. Adapted from reference (12). 상하좌우 4부위가운데 3부위에통증이있어야하고 24군데의압통점가운데 11군데이상에서압통을호소할때섬유근통으로진단할수있다고되어있다. 진단이애매한경우에는관련증상과징후를고려하여진단할수있다고되어있어 1990년미국류마티스학회의분류기준과아주흡사하지만 1990년분류기준에비해좀더유연하고합리적인기준으로보여진다. 이진단기준은 100명의섬유근통환자와 50명의정상대조군을비교분석하여개발된것으로 95% 의민감도와 96% 의특이도를보였다. 섬유근통의진단에있어가장획기적인사건은 1990년미국류마티스학회에서새로운분류기준 ( 표 5) 을제시한것이다 (1). 이분류기준이발표되면서섬유근통에관한역학, 병태생리, 그리고치료에이르기까지섬유근통전반에걸친연구가비약적인발전을하게된다. 1990년분류기준은두가지내용으로구성되어있는데 3개월이상지속되는만성전신통증이있으면서 18군데의압통점가운데 11 군데이상에서압통을호소할때섬유근통으로진단할수있다. 이기준은 293명의섬유근통환자와나이와성별이일치하면서다양한류마티스질환을가진 265명의대조군을대상으로통계적정확도 (accuracy) 를산출하여개발된것으로 88.4% 의민감도와 81.1% 의특이도를보였다. 이전에발표된 Yunus 기준과 Lautenschläger 기준에비해민감도와특이도가떨어지는것은 1990년분류기준이훨씬더표본수가컸고정상대조군이아닌환자대조군을대상으로했다는것에어느정도기인한다고볼수있다. 1990년분류기준은섬유근통에관한하나의통일된분류기준을제안함으로써섬유근통에대한연구를용이하게했다는 Table 5. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia* 1. History of chronic widespread pain. Definition. Pain is considered widespread when all of the following are present: pain in the left side of the body, pain in the right side of the body, pain above the waist, and pain below the waist. In addition, axial skeletal pain (cervical spine or anterior chest or thoracic spine or low back) must be present. In this definition, shoulder and buttock pain is considered as pain for each involved side. "Low back" pain is considered lower segment pain. 2. Pain in 11 of 18 tender point sites on digital palpation Definition. Pain, on digital palpation, must be present in at least 11 of the following 18 sites: Occiput: Bilateral, at the suboccipital muscle insertions. Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7. Trapezius: bilateral, at the midpoint of the upper border. Supraspinatus: bilateral, at origins, above the scapula spine near the medial border. Second rib: bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces. Lateral epicondyle: bilateral, 2 cm distal to the epicondyles. Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle. Greater trochanter: bilateral, posterior to the trochanteric prominence. Knee: bilateral, at the medial fat pad proximal to the joint line. Digital palpation should be performed with an approximate force of 4 kg. For a tender point to be considered "positive" the subject must state that the palpation was painful. "Tender is not to be considered "painful." *For classification purposes, patients are considered to have fibromyalgia if both criteria are satisfied. Widespread pain must have been present for at least 3 months. The presence of a second clinical disorder does not exclude the diagnosis of fibromyalgia. Adapted from reference (1).
156 이신석 점에서긍정적인의미를부여할수있지만진단기준이아니라는점, 만성전신통증이있는환자가운데극단적으로심한상태의환자만을섬유근통으로분류하였다는점, 그리고나머지만성전신통증환자에대해서는어떻게접근을해야하는지구체적인지침이없다는점에서보완될필요성이있었다. 특히압통점검사와관련해서는많은논란이있어왔다. 섬유근통의병태생리가중추신경계에서통증을조절하는데문제가있어섬유근통이발생한다는사실이널리받아들여지고있는데압통점검사가자칫근육자체에문제가있어섬유근통이발생하는것처럼비쳐질수있다는점에서압통점검사의필요성이의문시되어왔다. 또한현실적인문제점으로압통점검사가일차진료의사들사이에서거의시행되지않고심지어는많은일차진료의사들이압통점검사하는방법을모른다는것이다 (13). 한편 1990년분류기준은섬유근통의통증에초점이맞춰져있기때문에섬유근통환자에서흔히동반되는수면장애, 피로, 신체증상과같은섬유근통의주된증상에관한내용이빠져있어이들증상이진단기준에포함될필요성이제기되어왔다 (14). 따라서이러한문제점들을개선시키기위해새로운진단기준의개발필요성이대두되어왔다. 1990년분류기준을개발했던 Wolfe는이러한필요를반영하여 2003년 서베이기준 (Survey criteria) 으로불리는새로운진단기준을제시하였다 (15). 이기준은 12,799명의류마티스관절염, 골관절염, 섬유근통환자들을대상으로우편설문을실시한다음 Mokken 분석과 Rasch 분석을통해개발된것으로표 6에서보는것처럼두가지내용으로구성되어있다. 첫째는압통점검사대신신체부위를 19개로나누어환자가지난한주간통증을느꼈던부위를표시하도록하는국소통증척도 (regional pain scale, 이하 RPS) 이고다른하나는시각아날로그척도 (visual analog scale, 이하 VAS) 로평가한피로의정도다. 섬유근통으로진단하기위해서는 RPS 19부위가운데 8부위이상에서통증이있어야하고 VAS로평가한피로도는 6점이상이어야한다고되어있다. 2006년에 Katz 등은 206명의섬유근통환자들을대상으로서베이기준, 1990년분류기준, 경험적인임상기준을서로비교하였는데서베이기준은 1990년분류기준과 72.3% 의환자에서일치했고임상기준과는 74.8% 에서일치한다고하였다 (16). 이들은섬유근통을진단하는데최적표준 (gold standard) 이라고할수있는진단기준이없는상태에서서베이기준은 1990년분류기준보다더우월하다고할수는없지만압통점검사를하지않고섬유근통을진단할수있다는점에서유용한진단기준이라고결론지었다. Wolfe와 Rasker는이후에서베이기준을수정하여 2006 년에증상강도척도 (Symptom Intensity scale) 라는새로운진단기준을발표하였다 (17). 표 6의수식에서보는것처럼증상강도척도는 RPS와피로 VAS를합쳐범주형변수가아닌하나의연속변수값으로만들어진것이다. Wolfe는 25,417명의섬유근통을포함한다양한류마티스질환환자들을대상으로이척도가섬유근통이있는환자와그렇지않은환자를구별하는데유용하다고하였고 5.25를기준으로했을때는서베이기준을만족하는섬유근통환자의 95% 를섬유근통으로진단할수있다고하였다. 하지만다양한류마티스질환이있는환자에서어느정도는증상강도가있고특히, 증상강도자체가인종, 성별, 흡연, 체질량지수, 교육정도, 동반질환, 장애, 사망등다양한변수와밀접한관계가있기때문에증상강도가높다고해서다섬유근통이라고하는것은무리가있다고하였다. 한편, Wilke와같은연구자는증상강도척도가섬유근통을진단하는데뿐만아니라약물치료후환자상태를평가하는데에도유용하다고하였다 (18). 하지만진단기준이라는것 Table 6. Survey criteria (2003) and Symptom Intensity Scale (2006) 1. Regional pain scale is composed of 19 nonarticular regions. Please indicate below the amount of pain and/or tenderness you have had over the past 7 days in each of the joint and body areas listed below. Jaw (left) Upper arm (left) Jaw (right) Upper arm (right) Chest Upper back Abdomen Hip (left) Forearm (left) Hip (right) Forearm (right) Shoulder (left) Upper leg (left) Shoulder (right) Upper leg (right) Neck Lower leg (left) Lower back Lower leg (right) 2. Fatigue visual analog scale. Please indicate current level of fatigue. Survey criteria: Regional pain scale score was 8 and VAS score for fatigue was 6. Symptom Intensity Scale score: [Fatigue VAS+(Regional pain scale score/2)]/2* *A score of >5.25 differentiated fibromyalgia from other rheumatic disease, identifying 95% of patients who satisfied the Survey criteria. Adapted from reference (15,17).
섬유근통의새로운진단기준 157 이질환의상태 (state) 보다는특성 (trait) 을반영해야한다는점을고려할때증상강도척도를진단기준으로보기에는무리가있고실제환자를대상으로한타당도 (validation) 검증과기존의다른진단기준들과의민감도, 특이도등을비교한연구가진행되어있지않아실제임상에서는널리활용되고있지않다. Wolfe 등은 2010년섬유근통의새로운진단기준을발표하게되는데이기준은미국류마티스학회의승인 (endorse) 을받아 2010년미국류마티스학회진단기준으로불리게된다 (19). 이기준은서베이기준과증상강도척도를개발했던 Wolfe가주도적으로참여하여개발했기때문에기존에발표되었던이들진단기준과연장선상에있는기준으로볼수있다. 이새로운기준은 829명의과거섬유근통을진단받았던환자들과정상인을대상으로 random forest 분석과 recursive partitioning 분석을통해개발된것으로표 7에서보는것처럼두가지내용으로구성되어있다. 첫째 는전신통증지수 (widespread pain index, 이하 WPI) 로과거서베이기준과증상강도척도에서 RPS로불리던것으로내용은동일한데이름만 WPI로바뀐것이다. WPI를평가하는방법은환자와직접면담을하면서한부위한부위씩표시하는방법이가장권장되고여의치않을때는환자에게체크리스트를주거나마네킹그림을주어서환자스스로표시하도록하는것도가능하다 (20). 두번째는증상중증도척도 (symptom severity scale) 로과거서베이기준과증상강도척도에서는피로정도만 VAS 점수로평가하던것을피로외에잠에서깨어날때의기분, 기억력이나집중력정도, 신체증상정도를추가하여이를각각 3점척도로평가하도록하였다. 증상중등도의평가는환자스스로설문지를보고답하는것이아니라검사자가환자와충분하게면담을한다음평가하도록되어있다. WPI와증상중증도의최대점수는각각 19점과 12점이고섬유근통으로진단하기위해서는 WPI가 7점이상이면서증상중증도가 Table 7. The 2010 American College of Rheumatology diagnostic criteria Criteria A patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met: 1. Widespread pain index (WPI) 7 and symptom severity (SS) scale score 5 or WPI 3-6 and SS scale score 9. 2. Symptoms have been present at a similar level for at least 3 months. 3. The patient does not have a disorder that would otherwise explain the pain. Ascertainment 1. WPI: note the number areas in which the patient has had pain over the last week. In how many areas has the patient had pain? Score will be between 0 and 19. Shoulder girdle, left; Hip (buttock, trochanter), left; Jaw, left; Upper back Shoulder girdle, right; Hip (buttock, trochanter), right; Jaw, right; Lower back Upper arm, left; Upper leg, left; Chest; Neck Upper arm, right; Upper leg, right; Abdomen Lower arm, left; Lower leg, left Lower arm, right; Lower leg, right 2. SS scale score: Fatigue Waking unrefreshed Cognitive symptoms For the each of the 3 symptoms above, indicate the level of severity over the past week using the following scale: 0=no problem 1=slight or mild problems, generally mild or intermittent 2=moderate, considerable problems, often present and/or at a moderate level 3=severe: pervasive, continuous, life-disturbing problems Considering somatic symptoms in general, indicate whether the patient has:* 0=no symptoms 1=few symptoms 2=a moderate number of symptoms 3=a great deal of symptoms The SS scale score is the sum of the severity of the 3 symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the extent (severity) of somatic symptoms in general. The final score is between 0 and 12. *Somatic symptoms that may be considered include muscle pain, irritable bowel syndrome, fatigue/tiredness, thinking or remembering problems, muscle weakness, headache, pain/cramps in the abdomen, numbness/tingling, dizziness, insomnia, depression, constipation, pain in the upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, itching, wheezing, Raynaud s phenomenon, hives/welts, ringing in ears, vomiting, heartburn, oral ulcers, loss of/change in taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, sun sensitivity, hearing difficulties, easy bruising, hair loss, frequent urination, painful urination, and bladder spasms. Adapted from reference (19).
158 이신석 5점이상이거나 WPI가 3 6점사이인경우에는증상중등도가 9점이상이어야한다. 2010년미국류마티스학회진단기준의의미는첫째는압통점검사를할필요없이설문만으로도진단이가능하게되었다는점이고, 둘째는다양한임상증상들을진단기준에포함시키게됨에따라상당수의만성전신통증환자들을섬유근통으로진단할수있게되었다는점에서그의의를찾을수있다고본다. 하지만이새로운기준에대해여러가지논란이있는것도사실이다. 먼저압통점검사가진단기준에서배제되었는데일부에서는압통점검사가섬유근통환자에서감소되어있는통증역치를객관적으로평가할수있는유일한방법이기때문에압통점검사가필요하다는의견도있다 (21). 한편, 2010년기준의경우압통점검사없이면담에의해진단이이루어지기때문에진단에소요되는시간이훨씬더길어지게되었다. 1990년분류기준에의해압통점검사를하게되면 1분이내에진단이가능하지만서베이기준은 2분, 2010년기준은최소 5분이상이소요되고제대로인터뷰를하자면 10분이상이소요되기때문에 2010년기준이널리보급되는데장애가될수도있다. 둘째, 전신홍반루푸스, 류마티스관절염과같은다른류마티스질환과의감별이어렵고, 특히근막통증증후군과의감별이어렵다는보고들이있다 (22). 이런논란이지속되고있는것은 1990년기준과달리 2010년기준은정상인을대상으로진단기준이개발되었기때문에당연한논란으로볼수있고 1990년분류기준의경우분류기준이발표된후여러연구들을통해타당도가검증된반 면 (23,24) 2010년진단기준은아직타당도가검증되지않은탓이크다고본다. 향후 2010년기준이좀더널리보급되려면류마티스질환을포함하여다양한만성질환들을대상으로타당도를검증하는일이시급하다고하겠다. 셋째, 2010년기준은서베이기준과증상강도척도처럼환자의증상에초점을맞춘것이기때문에앞서지적한것처럼질환의특성 (trait) 을충분히반영했다고보기어렵다. 따라서이것은앞으로도계속해서문제점으로지적될가능성이높다. 넷째, 2010년진단기준은 WPI와증상중등도가일정점수이상진단기준을만족시키면서통증을설명할수있는다른질환이없어야섬유근통으로진단할수있다고되어있다. 예를들어전신홍반루푸스, 류마티스관절염, 골관절염에의한이차성섬유근통은 1990년기준에의하면섬유근통으로진단하는데전혀문제가없지만 2010년기준에의하면동반질환이있는경우진단을할수없는경우가생길수있다 (25). 이차성섬유근통은임상증상, 치료, 약제에대한반응에있어원발성섬유근통과차이가없기때문에근래에는이둘을서로구분하지않은것이일반적이다. 따라서동반질환에관계없이섬유근통의증상이있으면섬유근통으로진단할수있도록하는것이바람직하지동반질환이있는경우진단을어렵게하는것은결코바람직하지않다고본다. 다섯째, 2010년진단기준은정상인에서 9.1% 의유병률을나타내는것으로보고되어있기때문에 1990년분류기준을적용했을때보다적어도 4배이상유병률이증가한다. 따라서, 어떤진단기준을적용했느냐에따라각기다른환자군이정의될가능성이높 Table 8. Fibromyalgia Criteria and Severity Scale (2011) Criteria A patient satisfies modified ACR 2010 fibromyalgia diagnostic criteria if the following 3 conditions are met: 1. Widespread Pain Index 7 and Symptom Severity Score 5 or Widespread Pain Index between 3-6 and Symptom Severity Score 9. 2. Symptoms have been present at a similar level for at least 3 months. 3. The patient does not have a disorder that would otherwise sufficiently explain the pain. Ascertainment 1. Widespread Pain Index (WPI): Note the number of areas in which the patient has had pain over the last week. In how many areas has the patient had pain? Score will be between 0 and 19. Shoulder girdle, Lt.; Hip (buttock, trochanter), Lt.; Jaw, Lt.; Upper Back Shoulder girdle, Rt.; Hip (buttock, trochanter), Rt.; Jaw, Rt.; Lower Back Upper Arm, Lt.; Upper Leg, Lt.; Chest; Neck Upper Arm, Rt.; Upper Leg, Rt.; Abdomen Lower Arm, Lt.; Lower Leg, Lt. Lower Arm, Rt.; Lower Leg, Rt. 2. Symptom Severity Score: Fatigue; Waking unrefreshed; Cognitive symptoms. For the each of these 3 symptoms, indicate the level of severity over the past week using the following scale: 0=No problem; 1=Slight or mild problems; generally mild or intermittent; 2=Moderate; considerable problems; often present and/or at a moderate level; 3=Severe: pervasive, continuous, life-disturbing problems. The Symptom Severity Score is the sum of the severity of the 3 symptoms (fatigue, waking unrefreshed, and cognitive symptoms) plus the sum of the number of the following symptoms occurring during the previous 6 months: headaches, pain or cramps in lower abdomen, and depression (0-3). The final score is between 0 and 12. Adapted from reference (27).
섬유근통의새로운진단기준 159 고여기에따라임상증상, 치료, 예후에대해서도서로다른결과가나올가능성이농후하다 (26). 향후 2010년진단기준이정착되려면앞서언급된많은문제점들을해결하기위한별도의임상연구들이추가로진행될필요가있다. 2010년진단기준과관련하여한가지언급될필요가있는것은원개발자가강조한대로이기준은 1990년분류기준을대체하기위해개발된것이아니라일차진료의사들이손쉽게섬유근통을진단할수있도록도움을주기위해개발되었다는것이다. 이러한개발자의개발의도를안다면 2010년기준의활용범위와용도를명확하게정의할수있을것으로판단된다. 국내의경우섬유근통으로보험급여가이루어지고있는약제들은부족한보험재정으로인해그급여기준이비정상적으로왜곡되어있어 1990년기준보다는 2010년기준을사용하여보다많은환자들이좀더쉽게섬유근통으로진단되고여기에따라적절한약물치료를받을수있어야한다고생각한다. 2011년 Wolfe 등은 2010년진단기준을좀더간편하게사용할수있도록하기위해진단기준을개정하였는데 2010 년기준과달리면담을통하지않고환자스스로증상을표시할수있도록하였다 (27). 표 8에서보는것처럼 WPI 와증상중등도의틀은그대로유지하고증상중등도의신체증상평가를 2010년기준과달리두통, 하복부통증, 우울의 3가지증상만평가함으로써신체증상을평가할수있도록하였다. 이기준은환자스스로증상을평가하기때문에증상자체가과대평가될가능성이있어개발자가강조한것처럼진단목적으로사용하기보다는역학적인조사목적으로사용하는것이바람직하다. 결론섬유근통의진단기준은 1977년 Smythe와 Moldofsky의진단기준이처음발표된이래다양한기준들이발표되어왔고최적표준이없는상태에서 1990년미국류마티스학회의분류기준이가장널리사용되어왔다. 1990년분류기준은섬유근통에관한역학, 병태생리, 그리고치료에이르기까지섬유근통전반에걸쳐많은영향을끼쳤지만몇몇제한점들이있어이를개선하고자하는노력이최근까지지속되어왔다. 2010년에발표된미국류마티스학회의진단기준은압통점검사없이설문만으로도진단을할수있게되었고다양한임상증상들을진단기준에포함시키게됨에따라상당수의만성전신통증환자들을섬유근통으로진단할수있게되었다는점에서큰의미가있지만여전히해결되어야할많은문제점들을가지고있어이를해결하기위한별도의임상연구들이추가로진행될필요가있다. 참고문헌 1. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33:160-72. 2. Goldenberg DL. Diagnosis and differential diagnosis of fibromyalgia. Am J Med 2009;122(12 Suppl):S14-21. 3. White KP, Nielson WR, Harth M, Ostbye T, Speechley M. Does the label "fibromyalgia" alter health status, function, and health service utilization? A prospective, within-group comparison in a community cohort of adults with chronic widespread pain. Arthritis Rheum 2002;47: 260-5. 4. Annemans L, Wessely S, Spaepen E, Caekelbergh K, Caubère JP, Le Lay K, et al. Health economic consequences related to the diagnosis of fibromyalgia syndrome. Arthritis Rheum 2008;58:895-902. 5. Gowers WR. Lecture on Lumbago: Its Lessons and Analogues: Delivered at the National Hospital for the Paralysed and Epileptic. Br Med J 1904;1:117-21. 6. Hench PK. Nonarticular rheumatism, 22nd rheumatism review: review of the American and English literature for the years 1973 and 1974. Arthritis Rheum 1976;19: S1081-9. 7. Smythe HA, Moldofsky H. Two contributions to understanding of the "fibrositis" syndrome. Bull Rheum Dis 1977;28:928-31. 8. Anch AM, Lue FA, MacLean AW, Moldofsky H. Sleep physiology and psychological aspects of the fibrositis (fibromyalgia) syndrome. Can J Psychol 1991;45:179-84. 9. Smythe HA. Nonarticular rheumatism and the fibrositis syndrome. In: Hollander JL, McCarthy DJ, eds. Arthritis and Allied Conditions. 9th ed. Philadelphia, Lea & Febiger, 1979. 10. Yunus M, Masi AT, Calabro JJ, Miller KA, Feigenbaum SL. Primary fibromyalgia (fibrositis): clinical study of 50 patients with matched normal controls. Semin Arthritis Rheum 1981;11:151-71. 11. Yunus MB, Masi AT, Aldag JC. Preliminary criteria for primary fibromyalgia syndrome (PFS): multivariate analysis of a consecutive series of PFS, other pain patients, and normal subjects. Clin Exp Rheumatol 1989;7:63-9. 12. Lautenschläger J, Brückle W, Seglias J, Müller W. Localized pressure pain in the diagnosis of generalized tendomyopathy (fibromyalgia). Z Rheumatol 1989;48:132-8. 13. Fitzcharles MA, Boulos P. Inaccuracy in the diagnosis of fibromyalgia syndrome: analysis of referrals. Rheumatology (Oxford) 2003;42:263-7. 14. Clauw DJ, Crofford LJ. Chronic widespread pain and fibromyalgia: what we know, and what we need to know. Best Pract Res Clin Rheumatol 2003;17:685-701. 15. Wolfe F. Pain extent and diagnosis: development and validation of the regional pain scale in 12,799 patients with rheumatic disease. J Rheumatol 2003;30:369-78. 16. Katz RS, Wolfe F, Michaud K. Fibromyalgia diagnosis: a comparison of clinical, survey, and American College of Rheumatology criteria. Arthritis Rheum 2006;54: 169-76. 17. Wolfe F, Rasker JJ. The Symptom Intensity Scale, fi-
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